Unempathic acts are simply the tail end of a bell curve, found in every population on the planet. If we want to replace the term "evil" with the term "empathy", we have to understand empathy closely. The key idea is that we all lie somewhere on an empathy spectrum. People said to be "evil" or cruel are simply at one extreme of the empathy spectrum. We can all be lined up along this spectrum of individual differences, based on how much empathy we have. At one end of this spectrum we find "zero degrees of empathy".

. . .

Zero degrees of empathy does not strike at random in the population. There are at least three well-defined routes to getting to this end-point: borderline, psychopathic, and borderline personality disorders. I group these as zero-negative because they have nothing positive to recommend them. They are unequivocally bad for the sufferer and for those around them. Of course these are not all the sub-types that exist. Indeed, alcohol, fatigue and depression are just a few examples of states that can temporarily reduce one's empathy, and schizophrenia is another example of a medical condition that can reduce one's empathy.

This comes after an introduction that recounts a childhood memory: when his father told him that the Nazis turned Jewish people into lampshades and soap. So people with BPD are "evil", "zero-negative" and have "zero degrees of empathy" (similar to the Nazis). This is quite a stunning characterization, in fact one that is not borne out by the literature. For example, one study showed that individuals with BPD are actually better than controls on a test of empathy designed by Baron-Cohen himself (Fertuck et al., 2009).2 That would be the Reading the Mind in the Eyes Test (RMET), "a measure of the capacity to discriminate the mental state of others from expressions in the eye region of the face." The study showed that:

The BPD group performed significantly better than the HC group on the RMET, particularly for the Total Score and Neutral emotional valences. Effect sizes were in the large range for the Total Score and for Neutral RMET performance. The results could not be accounted for by demographics, co-occurring Axis I or II conditions, medication status, abuse history, or emotional state. However, depression severity partially mediated the relationship between RMET and BPD status.

The authors concluded that this enhancement of facial emotion recognition abilities (or "enhanced sensitivity to the mental states of others") is what can get BPD persons in trouble socially. Consistent with this finding, another study found a double dissociation between two different types of empathy in BPD (Harari et al., 2010). Emotional empathy was slightly enhanced, whereas cognitive empathy was significantly impaired relative to controls.

Cognitive empathy, or the ability to take another person's perspective, is closely related to (or even synonymous with) theory of mind. On the other hand, emotional or affective empathy is "emotional contagion" - the ability to mirror an emotional response observed in another person and to experience it vicariously. The literature on emotional empathy in BPD isn't entirely consistent, however. Although Preißler and colleagues (2010) reported preserved (but not enhanced) performance on the RMET, they observed an impairment on the “Movie for the Assessment of Social Cognition” (MASC) in the BPD participants.

In his book, Baron-Cohen also provides a case study from another population with "zero degrees of empathy" -- the psychopath:

Paul's career of criminal behaviour had begun when he was as young as 13, when he had set fire to the school gym and sat in a tree across a field to watch it burn. He was expelled and from there went to three more schools, each time being expelled for aggression – starting fights in the playground, attacking a teacher who asked him to be quiet and even jumping on someone's head when they wouldn't let him join the football team.

Paul [currently in jail for murder] is clearly not the kind of guy you want to live near. Many would not hesitate to describe him as "evil". He is a psychopath – a Type P – though to give him the proper diagnostic label, he has antisocial personality disorder. He earns this label because he shows "a pervasive pattern of disregard for and violation of the rights of others that begins in childhood or adolescence, and continues into adulthood".

This sounds similar to the description of Cpl. Jeremy Morlock in The Kill Team, a recent article in Rolling Stone on the American soldiers in Afghanistan who killed innocent civilians and mutilated their corpses. [NOTE: I am not linking directly to this article because it contains very graphic and disturbing photographs. You'll find them within the online magazine if you want to see them.] According to Rolling Stone:

Before the military found itself short of troops in Afghanistan and Iraq, Morlock was the kind of bad-news kid who the Army might have passed on. He grew up not far from Sarah Palin in Wasilla, Alaska; his sister hung out with Bristol, and Morlock played hockey against Track. Back in those days, it seemed like he was constantly in trouble: getting drunk and into fights, driving without a license, leaving the scene of a serious car accident.

But it gets worse and escalates, just like with Paul: he committed the serious crime of spousal abuse only one month before being deployed. Unfortunately, he was only charged with "disorderly conduct" and then sent off to Afghanistan anyway:

Even after he joined the Army, Morlock continued to get into trouble. In 2009, a month before he deployed to Afghanistan, he was charged with disorderly conduct after burning his wife with a cigarette. After he arrived in Afghanistan, he did any drug he could get his hands on: opium, hash, Ambien, amitriptyline, flexeril, phenergan, codeine, trazodone.

So it seems that his antisocial character was well-established before he arrived in Afghanistan.3

Come on, Professor Baron-Cohen. Surely it's a stretch to compare Nazis and callous murderers without a conscience to affectively unstable, impulsive, and interpersonally difficult individuals who may be self-destructive or manipulative?

Clearly Type Ps differ in important ways to Type Bs, but they share the core feature of being zero-negative: their zero degrees of empathy can result in them doing cruel things to others.

The essential feature of this disorder is a pervasive pattern of instability of self-image, interpersonal relationships and mood. The person’s sense of identity is profoundly uncertain. Interpersonal relationships are unstable and intense, fluctuating between the extremes of idealisation and devaluation. There is often a terror of being alone, with great efforts made to avoid real or imagined abandonment. Affect is extremely unstable, with marked shifts from baseline mood to depression and anxiety usually lasting a few hours. Inappropriate anger and impulsive behaviour are common, and often this behaviour is self-harming. Suicidal threats and self-mutilation are common in more severe forms of this disorder.

Saturday, March 26, 2011

An article from January is making the rounds again. One in nextgov's exposé-like series on America's Broken Warriors, it highlighted the fact that 20% of U.S. active duty troops are on psychotropic medications. While this may not be a good thing, the article was filled with erroneous information about specific psych meds and general scare-mongering from antipsychiatry "experts" pitching their books. Let's take a look.

Army leaders are increasingly concerned about the growing use and abuse of prescription drugs by soldiers, but a Nextgov investigation shows a U.S. Central Command policy that allows troops a 90- or 180-day supply of highly addictive psychotropic drugs before they deploy to combat contributes to the problem.

The CENTCOM Central Nervous System Drug formulary includes drugs like Valium and Xanax, used to treat depression, as well as the antipsychotic Seroquel, originally developed to treat schizophrenia, bipolar disorders, mania and depression.

1. Valium (diazepam) and Xanax (alprazolam) are not used to treat depression. These sedative-hypnotic benzodiazepine medications are primarily used to treat anxiety disorders.

2. The atypical antipsychotic Seroquel (quetiapine) was originally developed to treat schizophrenia, although now it is prescribed for bipolar disorder and major depression. Off-label usage of quetiapine, including as a sleep aid, is controversial and I won't be discussing it further here. That topic could easily take up several posts of its own.

The article continues:

A June 2010 internal report from the Defense Department's Pharmacoeconomic Center at Fort Sam Houston in San Antonio showed that 213,972, or 20 percent of the 1.1 million active-duty troops surveyed, were taking some form of psychotropic drug: antidepressants, antipsychotics, sedative hypnotics, or other controlled substances.

Dr. Grace Jackson, a former Navy psychiatrist, told Nextgov she resigned her commission in 2002 "out of conscience, because I did not want to be a pill pusher." She believes psychotropic drugs have so many inherent dangers that "the CENTCOM CNS formulary is destroying the force," she said.

Here we see Dr. Jackson's antipsychiatry agenda first established. All psych drugs are bad. Also note that Dr. Jackson resigned in 2002, before the war in Iraq began on March 20, 2003. So she doesn't have first hand experience with current prescribing practices or the effects of these medications on troops in Iraq and Afghanistan, which is what the article is about.

We also have quotes from one of the leading antipsychiatry advocates, Dr. Peter Breggin:

Dr. Peter Breggin, an Ithaca, N.Y., psychiatrist who testified before a House Veterans Affairs Committee last September on the relationship between medication and veterans' suicides, said flatly, "You should not send troops into combat on psychotropic drugs." Medications on the CENTCOM CNS formulary can cause loss of judgment and self-control and could result in increased violence and suicidal impulses, Breggin said.

Dr. Breggin's credibility as an expert witness has been repeatedly questioned, however. I agree that mentally ill troops should not be sent into combat, but will also point out that untreated and unmedicated psychiatric disorders in a war zone can cause increases in violence and suicidal behavior.

Back to Dr. Jackson:

Jackson, the former Navy psychiatrist, now has a civilian practice in Greensboro, N.C. She said at least one drug on the CENTCOM formulary -- Depakote, an anticonvulsant, which military doctors prescribe for mood control -- carries serious physical risks for troops.

Really? Depakote (valproic acid) is an antiseizure medication also used to treat bipolar disorder. I would like to see statistics on how frequently it's prescribed for "mood control" in soldiers without bipolar disorder.1

Depakote is toxic to certain cells, including hair cells in the ears, and can lead to hearing loss. Troops in a howitzer battery who already run the risk of hearing loss should not take Depakote, she said.

3. Depakote is certainly not without its adverse effects, but hearing loss is an extremely rare side effect.2 In a study of 21 patients taking valproic acid (VPA) to control seizures, there were no differences in hearing thresholds between 125 and 16,000 Hz compared to age- and sex-matched controls (Incecik et al., 2007). In addition, there was no relationship between duration or dosage of drug and hearing levels.

The medication also can cause what she calls "cognitive toxicity," also known as Depakote dementia, impairing a person's ability to think and make decisions. Jackson said that while Depakote has been investigated as an adjunct therapy for cancer, its use has been limited due to the drug's effects on cognition.

While it's possible that VPA could produce impairments in some cognitive domains, proper studies are difficult because you have to control for the length of illness in untreated patients (since cognitive deficits can be caused by the disorder itself). One such report on currently medicated (n=33) and currently unmedicated (n=32) participants with bipolar depression failed to find group differences in visual memory and sustained attention (Holmes et al., 2008). Unfortunately, this study collapsed across participants on lithium and valproic acid. Further, the groups weren't matched on age, sex, and depression scores. Finally, the medicated individuals were more depressed, which might be expected to worsen performance on its own.

A double-blind cross-over design in healthy controls administered a relatively high dose of VPA for two weeks (800 mg the first week, 1,000 mg the second). There were no changes in memory, concentration, perceptual speed, motor speed, and subjective ratings relative to placebo (Trimble & Thompson, 1981). The drug did, however, slow response times in a category decision task. A review of the literature on cognition and anticonvulsants concluded: "Overall, deficits are subtle, especially in the therapeutic range" for valproic acid (Goldberg & Burdick, 2001). Not exactly a ringing endorsement for cognitive toxicity and Depakote dementia.

On to the next drug:

The antidepressant Wellbutrin, also on the CENTCOM formulary, likely poses a long-term risk of Parkinson's disease, especially for older troops, said Jackson, author of Drug-Induced Dementia: A Perfect Crime (AuthorHouse, 2009).

I did find a few case reports that bupropion can induce a parkinsonian-like condition within a week or two, especially in elderly patients, that abates upon discontinuation (Szuba et al., 1992; Cheng et al., 2009). This is not the same thing as increasing long-term risk for Parkinson's in "older troops" given the drug.

I think I'll stop for now. The rest of the article covers the addiction potential of alprazolam (well-supported by the literature), the dangers of quetiapine (an issue not discussed here), and an unsupported statement from Jackson that "Seroquel has the addictive potential of opioids, such heroin."

Although these psychotropic medications are not without their risks and adverse side-effects, neither are they a societal evil capable of producing a military force of deaf, demented, and parkinsonian troops.

Thursday, March 24, 2011

Exquisitely designed brain shaped pops featuring a sweet lemon flavor and a translucent yellow color. You can actually feel the creepy ridges of the brain matter as you lick the lollipop. These gourmet suckers are hand poured by a master candy craftsman using only certified organic ingredients. The long wooden sticks of these pops make them easy for making a fun candy brain bouquet.... the bouquet preferred by top neurologists!

Sunday, March 20, 2011

In our next installment of food-based behavior therapies to treat phobias in adults, we have a case report of combined exposure/M&M treatment (Kroll, 1975). First is a description of the client's fear of dogs:

The client was a 22-yr-old female graduate student with a strong fear and avoidance of dogs. She had been told by her parents that a large brown dog had knocked her over when she was a child, but she did not remember the incident nor did she attribute her fear to it. She could not remember any time in her life when she was not afraid of dogs. The intensity of her fear was unaffected by size or breed of dog. If she was alone and saw a dog approaching her, she became highly anxious and walked away very rapidly or, if possible, crossed the street to avoid an encounter. When leaving her house and seeing a dog, she either exited through the back door or waited until the dog left before walking outside. If she was walking with another person and unavoidably encountered a dog, she became intensely anxious and held onto the other person tightly while attempting to put the person between her and the dog.

Next is description of the treatment, which included voluntary food deprivation. Notice, however, that the client did not agree to 24 hrs without food:

The client was instructed not to eat anything for 12-hr prior to the treatment session. It was originally planned that she would undergo 24-hr food deprivation, but she did not think she could go without eating longer than 12-hr. Because among her favorite foods M & M's were most preferred, I decided on using them to inhibit anxiety. She was told that they would have greater reward value than any other food and would therefore increase the probability of successfully inhibiting anxiety elicited by a feared object.

And here we have evidence of the therapist's condescending attitude:

Since I had told her of other cases in which food was used as an anxiety inhibitor, she was receptive to the use of M & M's. (It should be noted that she was unaware of the client populations with whom M & M's are typically used.)

So the client bought a large bag of M&M's and went to an animal shelter, accompanied by the therapist. From the very beginning, the therapeutic value of the M&M's is not really clear, given the calming presence of the therapist:

Upon entering the room in which the dogs were caged, the client's initial response was fear. She made no attempt, however, to leave the room. Starting at a distance of about seven feet--the farthest away in the room that one could stand from the animals--I walked with the client around the room as far as possible from the cages while feeding her M & M's. ... At the end of the session which lasted approximately 2-hr, she reported feeling relaxed in the presence of the dogs. She expressed confidence that she could encounter dogs without fear or need to avoid them.

It's scientifically proven! M&M'S® can cure phobias in a single 2 hr session! However, that laughable conclusion was even questioned by the author at the end of the article:

The possibility exists that, instead of the feeding, or perhaps in addition to it, graduated exposure or therapist-client interaction or modeling were responsible, singly or in complex interaction for the client's improvement. As control observations were not made, one cannot rule out the possibility that the feeding was superfluous.

To end on a serious note, one application of this approach to behavior therapy is not a laughing matter at all, as noted in a comment on my last post by Michelle Dawson, author of The Autism Crisis blog:

You can find a 1970s use of extreme food deprivation at UCLA reported in this book. Lovaas' reported recommendation was 36hrs of food and liquid deprivation for a 4yr old. The purpose was to make the child "hungry and desperate enough to do anything for food." Instead the child got very sick, threw up bile, and was too tired and listless to work for his food.

Another book reports in passing the use of routine food deprivation as autism treatment by Lovaas at UCLA, within the most famous autism study ever.

To my knowledge there has never been any criticism of this kind of practice published in any journal.

Monday, March 14, 2011

In 1973, Bryntwick and Solyom published a paper on a new method of behavior therapy for elevator phobia, which involved depriving their clients of food and water for 24 hours. The rationale for their unorthodox approach was as follows:

Fear habits in the animal laboratory have been diminished by first depriving the subject of food and then rewarding him with it in the fear provoking situation (Masserman, 1943; Wolpe, 1958). To apply this technique to clinical subjects has generally been considered "unthinkable". The present report illustrates the clinical effectiveness in the treatment of two elevator phobic subjects.

Apparently, both of the patients voluntarily agreed to forgo eating and drinking for one day. Here is the background information on the two elevator phobic subjects, one of whom had good reason to be phobic (in my view):

Mr. B.M., a 32-yr-old businessman, had suffered from an elevator phobia for about 5 yr. He attributed his fear to two occasions within a 2-week period when he was trapped in an elevator for a few minutes. Since then he would climb 16 floors rather than take an elevator. Several times daily he climbed three flights of stairs to his office. On a 0-4 point scale, he rated his fear of elevators as 4, corresponding to "terrifying panic attacks if avoidance impossible". No other obvious psychopathology was apparent...

Mr. W.H., a 19-yr-old student, had suffered from travel and claustrophobia for approximately 3 yr. He was markedly obsessive, being very orderly, meticulous and hesitant, with a tendency to ruminate. One manifestation of his claustrophobia was avoidance of elevators. He also rated his elevator phobia at 4...

As for treatment, both patients had failed "aversion relief therapy" for elevator phobia, so the authors found it appropriate to use feeding as a counter-conditioner in vivo.

Each patient, after agreeing to the new procedure, was instructed not to eat or drink for 24 hr prior to the treatment session. After that deprivation the patient was led to an elevator where he found a table attractively arranged with his most preferred foods. For the next 35 rain he sat eating his dinner while the elevator moved up and down. At the end of the session, the patient was encouraged to take self-service elevators in as many different buildings as possible.

Both patients reported minimal anxiety and for the first time did not avoid taking elevators.

Possible scenario for the elevator exposure dining experience.

Unfortunately, Mr. W.H. had a relapse after being the victim of a cruel prank:

One week after the first session, however, Mr. W.H. was riding in an elevator when the building superintendent, also in the elevator, stopped it with the comment, "I wonder if it will start again". Although the elevator was stopped for only 5 sec, Mr. W.H.'s anxiety rose to its original intensity.

No matter, all was not lost. Two weeks later a booster session eliminated his elevator phobia once again. Both patients were reportedly "phobia free" two years later.

Not everyone in the behavior therapy community was pleased with this approach, however. Rosen and Orenstein (1974) were quite critical of the treatment, and nearly called the food deprivation aspect a farce:

...There appears to be no evidence to support the position that such deprivation significantly adds to the effectiveness of a treatment program based on in vivo exposure alone. The first author’s own experience with an “elevator phobic” suggests that avoidance of elevators can be eliminated in a single in vivo session without recourse to theoretical “counter-conditioners”. The client spent 45 min riding in the elevator of an eight story building sometimes accompanied by the therapist and sometimes on her own. During the session there were large reductions in her self-reported anxiety. Four days later the client rode in the same elevator on her own. She has since ridden in other elevators demonstrating what could be called a “generalization of treatment effects”.

This particular patient missed out on the elevator fine dining experience, though...

Friday, March 04, 2011

Semantic dementia is a neurodegenerative disorder in the general class of frontotemporal lobar degeneration. Atrophy occurs bilaterally in the anterior temporal lobes, with the left hemisphere affected to a greater extent (Lambon Ralph & Patterson, 2008). Patients gradually lose semantic memory abilities (e.g., memory for word meanings and conceptual knowledge). Alterations in personality, interests, and tastes can be observed in some patients. A unique case study documented an increasing interest in polka music with the progression of semantic dementia (Boeve & Geda, 2001):

A man exhibited typical features of semantic dementia (Neary et al., 1998), with onset at age 52. At age 55, he became infatuated with polka music. He would sit in his car in the garage and listen to polka on the radio or on cassettes, often for as long as 12 to 18 hours. Whereas some may argue that enjoying polka music is in itself pathologic, we view this patient’s new appreciation of polka similar to that recently described with pop music in two patients with frontotemporal dementia (Geroldi et al., 2000). Thus, heterogeneity in musical taste is yet one more dimension bridging semantic dementia and frontotemporal dementia.

The progression of atrophy in the temporal lobes is shown below. The relative preservation of the frontal lobes is noteworthy.

Figure (Boeve & Geda, 2001). Representative T1-weighted coronal MRI at ages 53 (top row) and 55 (bottom row) are shown. Note progressive atrophy of the left amygdala and temporal cortex, and although a definitive causal relationship cannot be made, the right amygdala and temporal cortex atrophy has evolved in concert with the patient’s polka music obsession.

About Me

Born in West Virginia in 1980, The Neurocritic embarked upon a roadtrip across America at the age of thirteen with his mother. She abandoned him when they reached San Francisco and The Neurocritic descended into a spiral of drug abuse and prostitution. At fifteen, The Neurocritic's psychiatrist encouraged him to start writing as a form of therapy.